Most studies on willingness to PDS are limited to health professionals or students [43,44,45,46], although some reports have focused on other populations, such as blood donors [47], registered body donors [30], ethnicities [48], patients, and relatives [49]. With respect to Mexico, as far as we know, there is only one PDS willingness study, which was limited to the staff and students of an anatomy department [37]. The hypothesis that a small proportion of the northern Mexican population is willing to donate their post-mortem body to science and that non-health-related persons might be more willing than health-related professionals seemed accurate for a cohort recruited online from a private university community.

A promising result was that 70.7% of the responder cohort was willing to PDS. Another Mexican study on PDS willingness reported a similar proportion [37]. This latter cohort differed from ours in population and recruitment strategy. Rather than a study population limited to students and staff of an anatomy department, our population included students and personnel from an entire university community. With respect to recruitment strategy, rather than an invitation in a working or study environment, our online convenience strategy presented limited control and less social pressure for the study population. The convenience recruitment strategy seemed to yield a self-selected cohort with a double bias, altruism, and interest in the topic, which is discussed further in the profile section.

The proportion of our cohort willing to PDS represented 0.78% of the target population. A relatively high number in comparison to 0.17% of the Mexican population registered as organ donors at the federal transplant registry [20, 50]. It is also high in comparison to a progressive society, such as the Dutch, where 0.1% of the population was registered as a body donor in 2013 [51]. The comparison of survey with registry data is awkward because of the well-known discrepancy between willingness and behavior [21]. Two relevant aspects of these low proportions are the following: 1. The proportions tend to below the significance threshold, indicating that PDS willing people are significantly different from the general population. Most countries and cultures have a small, distinctive cohort willing to PDS [51]; 2. Low proportions tend to be sufficient; high proportions may generate an undesirable surplus of bodies [51]. Thus, a willingness rate of 0.78% for the university population may seem small but may be sufficient for successful PDS programs, especially if it also occurs at a national level.

With respect to the profile of respondents willing to PDS, age had the strongest impact in our well-educated cohort at a private university. Mature adults were more willing toward PDS than younger adults. A similar age effect was reported from a PDS survey among staff and students from an anatomy department at a public university in northern Mexico [37] and is consistent with most international data [52, 53]. In contrast, a POD survey among the general population in central Mexico found that older participants had a less favorable attitude [54]. In the latter study, lower levels of education among older people may have been a confounding factor. Indeed, less education has been associated with more misconceptions, more psychological barriers, and less willingness [22]. Education at high school level or beyond is an important factor for a positive attitude toward PDS [31, 52]. The importance of age and education has been reported repeatedly in a variety of cultures [29, 31, 52,53,54,55], including Mexico [54]. As the education level of our cohort was relatively high, the impact of lower education was not evident. Hence, in our cohort, mature age was the most distinctive sociodemographic trait among people willing to PDS.

Among the young adult respondents (up to 40years old), academic interest had a strong correlation with PDS willingness. Those with an academic interest in the humanities and social sciences were the most willing, while those interested in technology and business were the least willing to PDS. In contrast, a survey among Indian registered body donors found that engineers and businesspeople were more abundant than donors from the humanities and social sciences [31]. These contrasting findings may in part be due to cultural differences. The relatively low rate of PD behavior among medical physicians across different countries and cultures is notable [31, 52, 56]. Willingness to self-donate tends to decline after dissection experiences, while a positive attitude toward PDS by strangers remains intact [57,58,59]. This phenomenon was not found in the single study on PDS willingness among Mexican anatomy students [37]. However, an aversion due to dissection experience could explain why our respondents from the health sciences did not have the highest PDS willingness rate. In our cohort, all respondents from health sciences were in favor of POD, but only 50% reported being registered as such. Respondents from the social sciences had the highest consistency rate, with 70% reporting being registered as POD. The relationship between career choice, PD willingness, and consistent behavior is complex and beyond the scope of this study. To summarize, our university cohort showed a higher willingness to PDS among respondents from the humanities and social sciences, who also had the highest rate of self-reported consistent behavior toward PD.

Socioaffective characteristics, such as social responsibility, benevolence, altruism, empathy, social responsibility, and trust have been reported worldwide as motivators for blood donation, POD, and PDS [60,61,62], including for a Mexican POD study [38]. Our cohort appeared to have an altruistic bias. An unexpectedly large proportion of respondents had previously donated blood (49.0%) and/or self-reported being a registered POD (44.8%). Although there are no reference data available for the target population, there is circumstantial evidence. Mexico is known for low rates of altruistic blood donation [63], and this also applies to Nuevo Len [64], the state where most of the respondents came from. Although this study did not distinguish between altruistic and family-motivated blood donation, the relatively high proportion of blood donors in the respondent cohort suggests an altruistic bias. The proportion of registered organ donors in our study (44.8%) was higher than that reported in a Mexican POD survey among nursing and medical students (1135%) from public and private universities in central Mexico [65]. In contrast to this latter study, where the POD registry was supported by physical evidence, our anonymous online study relied on self-reports. Although there was no social pressure in our study, over-reporting of actions considered socially desirable cannot be ruled out. Our recruitment method may have favored the self-selection of a cohort with an interest in the topic and an altruistic bias. The POD registry proportions are much higher than data from the federal POD registry (0.17%) [20, 50], probably due to their higher accessibility as they are linked to the issuance of a drivers license. Altogether, our self-selected cohort seems to present an altruistic bias, which may explain the high proportion willing to PDS.

In our cohort, the proportion with willingness to POD (90.9%) was higher than that with willingness to PDS (70.7%). This is a common finding [58, 59, 66]. What determines these differences? People may imagine a greater disfigurement of the post-mortem body when it is destined for PDS than for POD. Mutilation of the post-mortem body, fear, and family considerations are strong contributors to POD and PDS aversion [57,58,59, 66], also in Mexico [38]. People may think that saving a life-saving POD is a better cause than PDS. Indeed, the utilitarian motive has been recognized for general PD willingness, including in Mexico [21, 38, 67]. In the free comments section of our survey, post-mortem usefulness was mentioned in a positive sense. However, for one POD-positive respondent, the uselessness of science was an argument against PDS, which still underscores the importance of the utilitarian motive. The most common positive terms in the comments were interesting and social awareness. Social awareness and interest are helpful first steps toward body donation as they motivate a search for information [21]. Importantly, the willingness rate tends to be higher than the rate of compliant behavior, as we noticed in the compliance of POD donors. The willingness-behavior discrepancy is not limited to PD but has been observed in many areas [68, 69]. A profound sociopsychological analysis of this phenomenon, although interesting, goes beyond the aims of this study.

With respect to cultural aspects, Mexico is portrayed for its idiosyncratic, ludic feelings toward death as an entity. The stereotype of Mexican death cults is accurate as an identity marker, but inaccurate because it is a one-sided exaggeration that fails to describe the full range of emotions that every human being experiences when confronted by death. Indeed, few Mexicans display ludic stoicism toward their own death and illness [70]. As in most countries and cultures, Mexicans vary not only individually but also by class, ethnicity, and region. As in most countries, in Mexico there is a minority willing to PD. A worldwide profile can be summarized as follows: PDS-willing people are a minority characterized by the following motivators: altruism and usefulness which seem to increase with age and education. On the other hand, fear, mutilation, and family considerations are demotivators. In general, Western world cultures have a higher prevalence of PDS willing people, but willingness to PDS exists in a minority in almost all cultures.

Valid responses represented only 1.1% of the target population. Web-based recruitment may not have reached the target population completely. Additionally, the tendency to not participate when holding a negative attitude towards PDS may explain the low participation rate. Due to the low response rate, the results are not representative of the target population and only describe the responder cohort. Recruitment difficulties for a PD survey have been reported previously [71]. Additionally, there is probably a nonresponse error, as 76.7% of visitors to the survey site did not proceed beyond the informed consent. This group was likely interested in the topic but discouraged for unknown reasons at the first step. Reasons for discouragement could be: i) the length or content of the informed consent, and ii) the time investment required, among others. Furthermore, 17.3% dropped out before completing the questionnaire. These dropouts may have been due to technical reasons, the length of the questionnaire, being disgraced by certain items, or other reasons. In the study design and during the pilot study, it was determined and verified that the questionnaire could be completed within 15minutes. This is important, as it is known that data quality declines with longer surveys [72]. Furthermore, it is probable that the responder cohort had a sampling bias, with community members who were less attentive to the institutional sites and news board being underrepresented. Moreover, as mentioned earlier, an altruistic bias was perceived in the responder cohort. An incentive might have diminished this sampling bias. The altruistic bias may be smaller than it seems in case blood donation and POD registry were over-reported, as they may have been perceived as desirable answers. Overall, convenience recruitment and online surveys generate several reliability issues that are common in online surveys [73]. Because of recruitment issues, the 70.2% PDS willingness cannot be extrapolated to the target population, and can be extrapolated even less to the Mexican population. However, the existence of this nonrepresentative, small (0.78%), altruism-biased, PDS-willing group is relevant and promising as it may be extrapolatable to the Mexican population. Future studies will verify that.

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